6265 E RIO GRANDE DR (2)Permit Types
BLD ELE MEC PLM
X
Permit Number: BLD2023-00869 '
Issued: 02/22/2023
www.anaheim.net/building
(714)765-4626
Quarter Section: 197
CITY OF ANAHEIM.
Site Address: 6265 E RIO GRANDE DR, ANAHEIM, CA 92807
Legal Description: N TR 5778 BLK LOT 72
APN:35606105
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfansure for worker's compensation. Issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
1 have and will maintain worker's compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: ACE AMERICAN INSURANCE COMPANY Policy No.: WCUC68916446 Expiration Date: 3/1/2023
Name of Agent: Phone No.:
JAertify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the
worker's compensation laws of California, and agree that, if I should become subject to the workers compensation provisions of Section 3700 of the
bor Cod s rthwith comply with those provisions. I
123
Signature of Applicant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED C9XTRACTOWS DECLARATION:
1 hereby apfiunder the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Proles si s Co ,and my IIIs In full force and effect.
Contractor Signature Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
602331 09/30/2024 C10, B, D12, C-2, C39, C-6, C17, C36, D34, D41, D24
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